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Treating secondary breast cancer
Treating secondary breast cancer
Deciding on a treatment for secondary breast cancer
Although it canít usually be cured, secondary breast cancer can usually be effectively controlled for a long time.
There are many different factors which doctors need to consider when deciding which may be the best treatment for you.
Where the cancer is
One of the most important factors will be which part of your body is affected by the secondary cancer cells.
Many breast cancer cells contain proteins known as oestrogen receptors. A cancer which contains a certain proportion of these proteins is described as oestrogen-receptor positive (ER+). About 6 out of 10 (60%) of breast cancers are oestrogen-receptor positive. The more oestrogen-receptors a cancer cell has, the more likely it is to be controlled by hormonal therapy.
If a cancer cell has very few or no oestrogen-receptors, it is called an oestrogen-receptor negative (ER-) cancer. Hormonal therapies do not work for ER negative breast cancers. Oestrogen-receptors are known as ER because of the American spelling of oestrogen as estrogen.
Whether or not you have had the menopause (change of life) is an important factor in deciding on treatment. Before the menopause, women have high levels of female hormones circulating in their bodies, whereas afterwards the levels of these hormones are lower.
In women who have had their menopause, most of the female hormones are produced by converting androgens from the adrenal glands into oestrogen. This influences which hormonal treatment will control the secondary breast cancer cells best.
Growth factor receptors
Your cancer cells may also be tested to see if they have receptors for particular proteins, known as growth factors, on their surface. The cancer cells will be tested for a type of growth factor receptor known as HER2.
Women with a high number of HER2 receptors are known as being HER2-positive (HER2+), and they may benefit from treatment with a type of biological therapy called trastuzumab (Herceptin®).
About 1 in 5 women (20%) have HER2+ breast cancer. These women may also benefit from a newer type of biological therapy called lapatinib (Tyverb®), which inhibits both the HER2 receptor, and another similar receptor called EGFR.
Other factors your doctor will take into consideration include your age and general health, whether the secondary cancer is slow growing (low-grade) or more faster-growing (high- grade) and which treatment, if any, you have had in the past.
The staging and grading of breast cancer is explained in our booklet about primary breast cancer.
Chemotherapy drugs, hormonal therapies and biological therapy drugs are carried round the body in the bloodstream so can treat cancer cells wherever they are in the body. This is known as systemic therapy.
Radiotherapy or surgery treats one area at a time and can be very helpful in treating individual areas of cancer, particularly in the bones or parts of the brain or the skin.
Doctors try to treat women with secondary breast cancer with the treatment that is most likely to control the breast cancer and cause the fewest side effects.
Planning treatment for secondary breast cancer
How treatment is planned
Your doctor will recommend the best treatment for you after taking into account all the factors discussed in the previous section. Feel free to ask how the treatment works and how it may affect you. You can also ask why the doctor has chosen a particular treatment.
You can discuss the effect that your treatment may have with your partner, family, doctor, nurses, or other therapists or counsellors if you wish. Many women find that being involved in the treatment decision helps them to have a sense of control over the cancer and their emotions.
Some women find that their secondary breast cancer may be controlled for a time by one treatment, and they then need to change to a different treatment when the cancer starts to grow again. Sometimes several different treatments may be given, one after the other.
Most doctors understand that you may want some time to think about their recommendations and any other treatment options. It can be hard to take in all the information about a treatment, especially if you have just learned that your cancer has spread.
Not all women want to be involved in decisions about their treatment. You may feel you have enough on your mind in coming to terms with the spread of your cancer and that you donít want to make decisions about your treatment. In this case, you shouldn't feel under any pressure to get fully involved in treatment decisions. Doctors are aware that individual women have different ways of coping with their cancer and will respect your wishes.
Benefits and disadvantages of treatment
Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Although many of the treatments can cause side effects, these can usually be controlled with medicines. Some people ask what would happen if they did not have any treatment.
With secondary breast cancer, the aim of treatment is to control the cancer for as long as possible, leading to an improvement in symptoms and a good quality of life. Most women find that the treatment shrinks the cancer or stops it from growing. However, for some women the treatment will not have an effect on the cancer and they will get the side effects of the treatment with little benefit.
Making decisions about treatment in these circumstances is always difficult, and you may want to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, with medicines to control any symptoms.
Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should be given full information about:
- the type and extent of the treatment you are advised to have
- the advantages and disadvantages of the treatment
- any other treatments that may be available
- any significant risks or side effects of the treatment.
If you don't understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it's not unusual for people to need repeated explanations.
It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.
Patients often feel that hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions. You can always ask for more time to decide about the treatment if you feel that you canít make a decision when it is first explained to you.
You are also free to choose not to have treatment. The staff can explain what may happen if you do not have it. It is essential to tell a doctor or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.
Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a patient. Even so, you may want to have another medical opinion. Either your specialist, or your GP, should be willing to refer you to another specialist for a second opinion if you feel it will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.
If you do go for a second opinion, it may be a good idea to take a friend or relative with you. You may find it useful to have a list of questions ready so that you can make sure your concerns are covered during the discussion
Hormonal therapies for secondary breast cancer
What is hormonal therapy?
Hormones are substances that occur naturally in the body, where they control the growth and activity of normal cells. Female hormones, particularly oestrogen, can encourage the growth of some breast cancer cells. Drugs which lower the level of oestrogen in the body, or that block oestrogen from attaching to the cancer cells, are used as treatment for some types of secondary breast cancer.
Many women are prescribed tamoxifen (one type of hormonal therapy) after their initial cancer treatment. For these women, if the cancer comes back, a different type of hormonal therapy such as an aromatase inhibitor may be used. Aromatase inhibitors are becoming more widely used after primary breast cancer treatment, and in this situation tamoxifen or a different type of aromatase inhibitor may be used if the cancer comes back. Some women have several types of hormonal therapy Ė one after the other.
When it is used
Hormonal therapy only works for women who have oestrogen-receptor positive (ER+) cancers. They can be effective in controlling slow-growing cancers affecting the bones, the lymph glands, the fatty tissue under the skin or the skin itself. Hormonal therapy can also be used for secondary breast cancer in the liver and lung.
One advantage of hormonal treatments is that they are easy to take and although side effects can occasionally be troublesome, they are rarely serious. Another advantage is that there are many different hormonal treatments available so if one doesnít work, or stops working, others can be tried. You will usually need to take hormonal therapies for a few weeks before your doctors can tell if they are working. Many hormonal treatments are available and more are being developed all the time.
The choice of hormonal therapy will depend upon whether you are pre or postmenopausal. Your doctor will be able to discuss which type of hormonal therapy treatment is best for you, based on all your relevant medical details.
Hormone therapy for postmenopausal women
After the menopause, oestrogen is produced mainly from male hormones (androgens) made by the adrenal glands. The androgens are changed into oestrogens in the fatty tissues of the body. Changing androgens into oestrogens is controlled by an enzyme called aromatase.
Postmenopausal women may be offered hormonal treatment with either an anti-oestrogen (such as tamoxifen) or an aromatase inhibitor.
Tamoxifen works by preventing oestrogen in the body from attaching to breast cancer cells and encouraging them to grow. It is used for both pre and postmenopausal women. Tamoxifen has been the most widely used hormonal therapy for breast cancer and it has been shown to be highly effective in reducing the chance of the cancer coming back. It can also be very effective in controlling secondary breast cancer for many women. Tamoxifen treatment can be continued for as long as it is effective in preventing the cancer cells from growing.
It is available as tamoxifen and Nolvadex® and is taken as a daily tablet. The side effects may include:
- hot flushes and sweats
- a tendency to put on weight (although this may be due to other effects such as going into the menopause)
- dryness of the vagina or an increased discharge from the vagina.
For many women, these side effects are mild and may reduce over time. However, some women continue to find the side effects of tamoxifen are a problem. If this happens, it is helpful to discuss this with your doctor as there are sometimes ways of reducing the effects.
We have a booklet on breast cancer and menopausal symptoms which has helpful tips.
In postmenopausal women, tamoxifen can slightly increase the risk of womb cancer, blood clots in the leg or lung, and strokes. Although this sounds very frightening, these effects are very rare and are usually curable and treatable. The benefits of tamoxifen in treating breast cancer outweigh the risks of side effects for most women.
Women who have secondary breast cancer in a bone may find that tamoxifen makes the bone pain worse for the first few days. This is known as tumour flare and it soon eases, but it is important to know that it might happen and that it is a temporary side effect of the drug. You should tell your doctor if it happens.
Fulvestrant is a newer anti-oestrogen drug that is only used to treat postmenopausal women. It is given as an injection once a month. It may be used after treatment with tamoxifen or aromatase inhibitors. It may also be used if women canít take tablets or may forget to take tablets. The side effects are similar to tamoxifen.
Drugs that block oestrogen production
Aromatase inhibitors work by blocking the production of oestrogen in the fatty tissues and the cancer itself, so they reduce the overall levels of oestrogen in the body and the cancer. Aromatase inhibitors are only used in postmenopausal women.
Aromatase inhibitors can cause thinning of the bones (osteoporosis). Women who already have osteoporosis, or are at risk of it, should have their bone strength checked before and during treatment with an aromatase inhibitor.
- Anastrozole (Arimidex®) is an aromatase inhibitor that is taken once a day as a tablet. Side effects include joint and muscle pain, vaginal dryness and nausea (feeling sick). It is slightly less likely to cause hot flushes than tamoxifen.
- Letrozole (Femara®) is also taken once a day as a tablet. Side effects are usually mild, and are similar to those of anastrozole.
- Exemestane (Aromasin®) is also taken as a tablet once a day. The side effects tend to be mild and are similar to anastrozole, but it may also cause diarrhoea in some women.
If the secondary breast cancer cells are not controlled by tamoxifen or aromatase inhibitors, artificial progesterone (progestogen) treatment may be used instead. Progesterone is a hormone that occurs naturally in women. Progestogens are stronger than progesterone and can be given as tablets or by injection into the muscle of the buttock. The commonest ones are megestrol acetate (Megace®) and medroxyprogesterone acetate (Farlutal®, Provera®). You may be given injections by your doctor or nurse.
Progestogens tend to cause more side effects than aromatase inhibitors. Although some women may feel slightly sick, most women find that progestogens increase their appetite. This may make them put on some weight, particularly in the stomach area. Some women also notice mild muscle cramps or slight vaginal bleeding (spotting). Rarely, progestogens can cause breathlessness. If this happens you should let your doctor know.
Hormonal therapy for premenopausal women
In women who have not had their menopause (change of life), most of the oestrogen in the body is produced by the ovaries. A small amount of oestrogen is made by changing androgens (produced by the adrenal glands) into oestrogen.
Premenopausal women may be offered hormonal treatment with the anti-oestrogen drug tamoxifen, or with a pituitary downregulator. They may also be offered treatment to stop the ovaries producing oestrogen, known as ovarian ablation.
Drugs known as pituitary downregulators reduce the production of oestrogen-stimulating hormones from the pituitary gland.
This lowers the level of oestrogen in the body. Pituitary downregulators can be used to lower oestrogen levels in women who have not yet had their menopause. Stopping the ovaries from producing oestrogen is sometimes called ovarian suppression. Using a pituitary downregulator has the same effect as removing the ovaries or giving them radiotherapy, but the effect is reversible. As a result, many doctors now recommend these drugs, rather than removing the ovaries with surgery or giving radiotherapy to stop them working.
They only work for oestrogen-positive breast cancers. The most commonly used pituitary downregulator for women with breast cancer is goserelin (Zoladex®). Goserelin brings on a temporary menopause, so many of its side effects are similar to those of the menopause and include hot flushes and sweating, joint pain, lowered sex drive, headaches and mood changes.
Many younger women find the symptoms of an early menopause difficult to deal with. Although some menopausal symptoms can be uncomfortable, many can be effectively treated.
In women who have not yet had the menopause, it is sometimes possible to stop the growth of their secondary breast cancer by stopping the ovaries from producing oestrogen. This is known as ovarian ablation, and can be done either by removing the ovaries with anoperation or by giving three or four radiotherapy treatments to the ovaries. In both cases, the ovaries stop producing female hormones, which brings on the menopause.
When surgery is used, periods stop immediately. You will need to stay in hospital for 1Ė2 days.
When radiotherapy is given to the ovaries, women usually have one more period, which may be heavy. Periods then stop completely. Contraception should be continued for three months after radiotherapy.
Unlike pituitary downregulators, these treatments will mean that a woman will no longer be able to have children. This definite end to being able to have children can be very distressing to women already coping with secondary breast cancer.
Healthcare staff will understand the emotional effect this treatment can have on women. You may find you want time to discuss the treatment with your partner, or someone close to you, before deciding to go ahead. You can also contact our cancer support service to talk through your feelings.
Chemotherapy for secondary breast cancer
Chemotherapy is the use of anti-cancer drugs, known as cytotoxic drugs, to destroy cancer cells. The drugs travel in the bloodstream to attack cancer cells throughout the body.
Chemotherapy may be used if the secondary cancer is growing quickly or has affected your liver or lungs. It may also be used after hormonal therapy if the hormonal therapy is no longer controlling the cancer, or if it's known that the cancer will not respond to hormonal therapy.
The chemotherapy drugs used
Many different chemotherapy drugs are used to treat secondary breast cancer. The drugs can either be used on their own (single agents) or together (combination chemotherapy).
Among the most commonly used chemotherapy treatments are:
- AC (doxorubicin and cyclophosphamide)
- FEC (5-Fluorouracil, epirubicin and cyclophosphamide)
- CMF (cyclophosphamide, methotrexate and 5-fluorouracil)
- Docetaxel (Taxotere®) or paclitaxel (Taxol®).
A chemotherapy tablet called capecitabine (Xeloda®) is sometimes used, usually on its own but sometimes in combination with docetaxel.
Your oncologist (cancer doctor) is the best person to decide which type of chemotherapy treatment is suitable for you, and can discuss the benefits and possible side effects with you.
How it is given
Chemotherapy is usually given as a series of treatments known as cycles. Drugs may be given weekly or every three weeks. Your complete treatment may last for several months. Although some chemotherapy drugs can be given as tablets or capsules (orally) to be taken at home, most are given by injection into a vein in the arm (intravenously). Chemotherapy into a vein is usually given in the chemotherapy department as a day case.
Side effects of chemotherapy
Chemotherapy can cause unpleasant side effects, but for women whose cancer has spread it can also make them feel better by relieving the symptoms of the cancer. The side effects can usually be well controlled with medicines. The main side effects are described below, along with information on controlling or reducing them.
Lowered resistance to infection
Chemotherapy can reduce the number of white blood cells produced by the bone marrow, making you more prone to infection. Contact your doctor or the hospital straightaway if:
- your temperature goes above 38ļC (100.5ļF)
- you suddenly feel ill (even with a normal temperature).
You will have a blood test before each cycle of chemotherapy to make sure that your cells have recovered. Occasionally it may be necessary to delay your treatment if your blood count is still low. Sometimes you may be given injections of a drug called G-CSF (granulocyte-colony stimulating factor). This is a type of protein that stimulates the bone marrow to produce more white blood cells. The injections are given under the skin (subcutaneously).
Bruising or bleeding
Chemotherapy can reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.
Anaemia (low number of red blood cells)
Nausea (feeling sick) and vomiting (being sick)
Some chemotherapy drugs can make you feel sick or even be sick. This can be helped by taking anti-sickness drugs (anti-emetics) which your doctor can prescribe.
Some chemotherapy drugs can make your mouth sore and may cause small ulcers. Regular mouthwashes are important and the nurses will show you how to do these properly.
If you don't feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet. Our booklet on diet and cancer has some useful tips on coping with eating problems.
Hair loss is a common side effect of some chemotherapy drugs. This can be very distressing for some people. However, there are many ways of covering up hair loss, including wigs, hats or scarves. You may be entitled to a free wig from the NHS. Your doctor or the nurse looking after you will be able to arrange for you to see a wig specialist. If your hair falls out, it should start to grow back within 3Ė6 months of the end of treatment.
Chemotherapy affects people in different ways. Some people find they are able to lead a fairly normal life during their treatment, but many become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it.
Although they may be hard to deal with at the time, these side effects will gradually disappear once your treatment is over.
Some women may find that chemotherapy makes them have their menopause early. See the page 'possible effects on your sex life' for more information.
Radiotherapy for secondary breast cancer
Radiotherapy uses high-energy rays to destroy cancer cells, while doing as little harm as possible to normal cells. It may be used for treating women with secondary breast cancer in one or more bones. It is also used to treat secondary cancer in the skin and lymph nodes. If secondary breast cancer cells have spread to parts of the brain, radiotherapy can often destroy the cancer cells and help to relieve any effects the brain tumour may cause.
Side effects of radiotherapy
Radiotherapy may cause some damage to normal cells surrounding the cancer. However, women with secondary breast cancer usually only need a short course of radiotherapy treatment with a relatively low dose of radiation, directed at specific areas of the body. Often, they have very few side effects.
You may become tired more easily. If the treatment is given to the abdomen or pelvis you may feel slightly sick for a while (nauseous) or have diarrhoea. These effects can be reduced by medicines which your doctor can prescribe.
If radiotherapy is used to treat secondary cancer cells affecting parts of the brain, it may make your hair fall out in the area in which it is given. The hair usually starts to grow back within a few months after the treatment has finished, although it may not grow back completely. This treatment can make you feel very sleepy or drowsy for a few weeks.
Radiotherapy itself is not painful, but the position you have to lie in for the few minutes it takes to do the treatment may be uncomfortable. If this is the case, it may help to take a painkiller half an hour before your treatment.
Radiotherapy does not make you radioactive and it is perfectly safe to be with other people, including children, after your treatment. If you have any questions about radiotherapy, you can ask your radiotherapist or the staff in the radiotherapy department.
Our booklet on radiotherapy provides detailed information about this treatment and its side effects.
Bisphosphonates for secondary breast cancer
Women who have secondary breast cancer affecting their bones may be treated with a group of drugs called bisphosphonates. Secondary cancer in a bone can cause it to become weakened. Bisphosphonates help to strengthen the bones and reduce the risk of fractures or breaks. The drugs can also help to relieve bone pain and may reduce the need for radiotherapy.
Cancer in the bones can cause calcium to be lost from the bone and seep into the bloodstream. This is called hypercalcaemia and can cause symptoms such as feeling sick, tiredness and sometimes confusion. Bisphosphonates can help to reduce the amount of calcium in the blood and relieve symptoms of hypercalcaemia.
Bisphosphonates can be given as tablets that are usually taken once or twice a day, or by drip (infusion) over a couple of hours as an outpatient. The main bisphosphonates used to treat secondary breast cancer are:
- Clodronate (Bonefos®, Loron®), which is a tablet that is taken once or twice a day.
- Pamidronate (Aredia®), which is given as a drip lasting about an hour, every 3Ė4 weeks.
- Zoledronic acid (Zometa®), which is given as a drip lasting about 15 minutes, once a month.
- Ibandronate (Bondronat®), which can be given as a tablet once a day, or as a drip given over 15 minutes, every 3Ė4 weeks.
Side effects of bisphosphonates
Side effects are generally mild, but can include sickness (nausea), headaches, and flu-like symptoms such as chills and muscle aches. Bisphosphonate tablets can sometimes cause diarrhoea, constipation and heartburn. When given by a drip (infusion) the side effects can include a temporary increase in bone pain, known as tumour flare. If this happens your doctor can prescribe painkillers until the side effect wears off.
Very rarely bisphosphonates can cause jaw problems, so it is important to let your dentist know if you are being treated with bisphosphonates. You should also tell your doctor if you develop any problems with your teeth.
Bisphosphonates are usually given for as long as they are working. If the bisphosphonate is given to reduce high levels of calcium it may only be given when itís needed.
Biological therapies for secondary breast cancer
Biological therapies are drugs that recognise and lock onto specific proteins (receptors) that are present in particular cancer cells. There are different types of biological therapies that work in slightly different ways.
Trastuzumab (also known as Herceptin®) is a type of drug known as a monoclonal antibody. It works by binding to particular proteins Ė HER2 receptors Ė on the surface of breast cancer cells. This slows down or stops the cancer cells dividing.
Herceptin® can only control a breast cancer if the breast cancer cells have a large number of the HER2 receptors on their surface (see treatment overview). Around 1 in 5 (20%) of women will have a large number of receptors - this is known as being HER2-positive. Your doctor may have your cancer cells tested for HER2 protein.
The National Institute for Health and Clinical Excellence (NICE), recommend that women with secondary (advanced) breast cancer can be given:
- Herceptin® in combination with paclitaxel (Taxol®) chemotherapy. This combination is only given if you havenít previously been treated with chemotherapy for advanced breast cancer, and if you arenít suitable to be treated with chemotherapy drugs known as anthracyclines, such as epirubicin and doxorubicin.
- Herceptin® on its own if you have already had at least two different courses of chemotherapy for advanced breast cancer, including an anthracycline chemotherapy and a taxane chemotherapy, such as paclitaxel (Taxol) or docetaxel (Taxotere®). Hormonal therapy should also have been tried if appropriate.
Herceptin® is usually given once every three weeks. It is given as a drip (infusion) into a fine tube (cannula) inserted into a vein.
Lapatinib is a newer type of biological therapy known as a growth inhibitor that is effective against cancers that have large numbers of HER2 receptors on the surface. Growth inhibitors interfere with the way that cancer cells 'communicate' with each other and can affect the cancerís ability to develop.
Lapatinib is a tablet. It is given in combination with the chemotherapy drug capecitabine (Xeloda®), which is also a tablet. The National Institute for Health and Clinical Excellence (NICE) has not yet recommended the use of lapatinib in the treatment of advanced breast cancer. As a result it may not be possible to get the drug on the NHS.
Research - clinical trials for secondary breast cancer
Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.
Clinical trials may be carried out to:
- test new treatments, such as new chemotherapy drugs, gene therapy or cancer vaccines
- look at new combinations of existing treatments, or change the way they are given, to make them more effective or to reduce side effects
- compare the effectiveness of drugs used to control symptoms
- find out how cancer treatments work
- see which treatments are the most cost-effective.
Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.
Taking part in a trial
You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and develop new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in these trials. It is important to bear in mind that some treatments that look promising at first are often later found not to be as good as existing treatments, or to have side effects that outweigh the benefits. If you decide not to take part in a trial your decision will be respected and you do not have to give a reason. There will be no change in the way that you are treated by the hospital staff and you will be offered the standard treatment for your situation.
Blood and tumour samples
Many blood samples and bone marrow or tumour biopsies may be taken to help make the right diagnosis. You may be asked for your permission to use some of your samples for research into cancer. If you are taking part in a trial you may also be asked to give other samples which may be frozen and stored for future use, when new research techniques become available. These samples will have your name removed from them so you canít be identified.
The research may be carried out at the hospital where you are treated, or it may be at another hospital. This type of research takes a long time and results may not be available for many years. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.